Emergency And Municipal Services Tax / Occupation Privilege Tax Claim For Refund Form
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Emergency and Municipal Services Tax /
Keystone Municipal Collections
Occupation Privilege Tax
118 Wendel Road
Irwin, PA 15642
Claim For Refund
(724) 978-0300 fax (724) 978-0339
______________________
__________
Taxing District
Tax Year
Attach copy of pay stub or receipt and copy of PA-40 and W-2’s.
Name of Applicant___________________________________ Soc. Sec. No.______________
Address___________________________________ _________________ ______ ________
No. and Street
City
State
Zip
Check Status:
Self-Employed
Employee
Employer
INSTRUCTIONS
Application must be signed and filed with Keystone Municipal Collections.
Attach proof of payment (copy of receipt or pay stub showing employer withholding.)
PA-40 and W-2’s must be submitted when applying under #2 below.
*REFUND PROCESSING REQUIRES PROOF OF PAYMENT. ALLOW UP TO 90 DAYS FOR
PROCESSING.
REASON FOR YOUR CLAIM
1.
Multiple deduction or payment:
Attach copy of pay stub or receipt from each employer.
2.
Did not reach minimum earnings for district in which tax was deducted:
List your total
earnings from all sources of income within the calendar year, and identify the employer who deducted the tax
PA-40
from your wages. The tax year includes January 1 to December 31. Copy of pay stub or receipt,
and
W-2’s must be attached. (NO COPIES – NO REFUND)
I declare under the penalty of law that the information herein is true and correct.
________________________________________________
_________________
Signature
Date
$_________________________
Amount of Refund Request
FOR OFFICE USE ONLY
Refund Amount ______________ Issued _______________ Check _____________ Key___________
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Parent category: Financial